 It's my pleasure to introduce Jacqueline Gehagen, Jackie Gehagen, who is here with us at Dalhousie and who wears many, many hats, both here and elsewhere. She's professor of health promotion, and she's head of the health promotion division in the School of Health and Human Performance. She is also director of the Gender and Health Promotion Studies Unit, which focuses on health research related to the intersectionality of gender and other key determinants of health. She holds cross-appointments in community health at EPI, international development studies, gender studies, occupational therapy, nursing, and she's an affiliate member of our very own Health Law Institute. So she's been involved in the field of HIV-8 advocacy, activism, and research for over 20 years now. Her current funded program of research focuses primarily on gendered aspects of HIV, PEPC, sexually transmitted infections, and sexual health outcomes. She is a founding member of the Atlantic Interdisciplinary Research Network. She's a member of the Ministerial Council on HIV-AIDS and a member of the Public Health Association of Nova Scotia. Jackie will be speaking with us today on criminalization of HIV non-disclosure, a public health or legal matter. Please join me in welcoming her. We're hoping for less of a full house considering the weather, and it is Friday after all, but welcome everybody having said that. Thank you for joining us for this presentation today on the discussion of criminalization of non-disclosure and whether or not HIV ought to be framed as a public health or legal matter, particularly in light of the recent Supreme Court decision. Before we get started, I'd like to express my sincere thanks to the Health Law Institute and in particular Elaine Gibson for inviting me here to speak to you today on the issue of framing HIV non-disclosure as a public health or legal issue. As noted, I've been involved in the HIV-AIDS movement in some capacity or other, mostly in research and advocacy for some 20 years, and as such I've followed with great interest the evolving responses at various levels from community, public health, and research, and have marveled at the incredible advances we've made on the one hand in moving an HIV diagnosis from a certain death sentence to the contested terrain of a chronic illness, largely as a result of the introduction of new, highly effective HIV treatments in the mid-1990s. Sorry, it's really, I mean, it's got to be minus 100 out there, so my nose is a little bit runny, so pardon me if I have to take a moment to blow it every now and again. I was a master's student presenting my research in 1996 at the International AIDS Conference when it was held in Vancouver and noted the much anticipated excitement around the discovery of what was, at least at the time, touted as the cure for HIV. Interestingly, all of the hype that came around the International AIDS Conference was quite incredible and quite palpable at the time. The benefit of hindsight, as is the case today in 2013, we can see that these treatments were not the magic bullet and would not allow us to get ahead of the epidemic in isolation from other issues. Specifically, these new HIV treatments were complex, required great tenacity on the part of the patient to adhere to the clinical guidelines, which meant adherence to 90% or higher levels in order to fully benefit. And for those who were able to adhere, these treatments came with a variety of treatment failures and toxicity issues, which contributed to a variety of comorbid conditions. As a health researcher working in the field of HIV prevention and treatment, I was interested in knowing how adherence to HIV treatment was impacted by other social determinants of health and as Elaine has pointed out, gender being a key determinant of health. Some of these determinants of health don't fit nicely into the public health agency of Canada, framing of determinants of health. So in the early days, we're dealing with determinants of health such as degree of outness about one's HIV status, about the complexity of medication regimens, which required strict timing of doses, nutritional considerations, refrigeration and simply the sheer burden of pills required on a daily basis. In other words, not a magic bullet. So part one, this is sort of a three-part talk and I have heated Elaine's advice to sort of balance the public health perspective with the legal perspective. So if you like the presentation, thank you, Elaine. If you don't like it, talk to Elaine. So there'll be three parts. So let's start with part one. So just go along with me as I tell you this story because some of you may look at this slide and say, why are we having this conversation? So what I'd like to do then by way of introduction is to offer a framing of the HIV AIDS pandemic through the lens of some of the worst pandemics we've experienced such as smallpox, the great flu of 1918, malaria, tuberculosis, cholera, etc. It's interesting to note that all of these pandemics came with their own unique biopsychosocial heuristics. The purpose of this historical nod to key pandemics as they're jumping off point for this discussion today about whether HIV is a public health issue or a legal issue is the recognition that we have as part of this collective human project struggled around the globe to balance these various health crises with evidence-informed approaches and responses and more recently with recognition of the more contextual determinants of health that serve to drive these various pandemics. Although deaths have occurred in the millions due to these pandemics and in many cases unfortunately we continue to see significant mortality and morbidity associated with one or more of these pandemics there remain a number of unresolved public health, legal and social questions about what is the best way to tackle these issues. HIV AIDS, I would argue, unlike many of these other earlier public health issues has some unique characteristics not seen among other pandemics and this is important for today's discussion. The early history of HIV AIDS at least in the North American context speaks to our collective dis-ease with issues associated with homosexuality, of injection drug use, of sex work and of the moral sorting of those who rank among unfortunate versus deserving victims of HIV infection. The very etiology or causation associated with HIV at least in the North American context suggests that the underlying factors contributing to escalating infection rates could be altered through strategic public health interventions. For example, access to an uptake of HIV testing, partner notification the availability and use of condoms and more recently and perhaps more controversially the use of HIV treatment as a form of HIV prevention you've probably heard Julio Montaner's group in BC the sort of stop AIDS project which is essentially get everybody on treatment as a way of reducing the community level of infectivity and that way you get rid of the virus essentially. So it is a controversial public health intervention so keep that in mind. It's interesting to note that while we are seeing what some would refer to as an erosion of the notion of AIDS exceptionalism we are seeing a simultaneous shifting of HIV as a public health issue to that of a legal issue with respect to this particular talk the use of criminal sanctions it could be argued is occurring where more traditional public health approaches are regarded as not having been sufficiently effective in stopping the spread of HIV. If we take from the word etiology as used in medical theories and public health how we study the cause of HIV and the reasons behind the spread of the virus we must I would argue attempt to balance the approaches we take to amassing our evidence base or so the question before you today is essentially this is HIV a public health or a legal matter? I'll start my talk with the role and function of public health and if all goes as planned I will end with the recent framing of the Supreme Court decision of Canada on criminalization of non-disclosure of HIV. My hope is by the end of my talk we can have an open dialogue about the relative pros and cons of each position and before I go any further just a gentle reminder to everybody in the room I am not a lawyer so if there are really hard questions for the law people ask Elaine my purpose is as I see it to provide you with information about both public health and legal perspectives so that this conversation can occur beyond the confines of this room and create a broader conversation back to your respective classrooms workplaces and communities everybody ready? okay while early responses to various pandemics can appear in retrospect somewhat lacking in rigor and scientific evidence that by today's standards would be a prerequisite to developing definitive statements about etiology course of treatment obviously where available social or legal sanctions and yet at the very least serve as a means of developing a discourse about the association between the presumed cause and impact on health outcomes rather we know now with the advantage of hindsight that many of the early epidemics were related to factors such as proximity of animals to humans including those used in the context of farming or in the case of domesticated animals increasing levels of settlement travel trade storage of food and with these advances the widespread expansion of sanitation needs and the increase in wells and ditches no big surprise all of which in turn created pools of standing water that allow for the proliferation of disease-carrying mosquitoes as well as an inviting habitat for other disease-carrying animals such as rats and mice throughout history we've seen the impact of global travel on the increasing exposure to new microbes in response public health has as part of its remit undertaken to address the spread of disease the control of outbreaks the surveillance of such outbreaks etc. We know from the World Health Organization definition of health that health is clearly more than the absence of disease rather and I quote health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity end quote it is noteworthy that this WHO globally accepted definition of health has not been amended since 1948 in essence public health in Canada as we know it aims to assure the conditions for people to be healthy we know that in Canada we have a well-structured public health system that takes the lead on a wide range of health policies and programs from immunization through inspection all with an eye to promoting and protecting the public's health more specifically with respect to HIV and AIDS under the federal initiative to address AIDS the public health agency of Canada are affectionately known as the Fackers in partnership with Health Canada the Canadian Institutes of Health Research and Correctional Service Canada work together for and I quote a Canada free from HIV and AIDS and the underlying conditions this is important so listen to this and the underlying conditions that make Canadians vulnerable to the epidemic in addition public health agency of Canada is responsible for HIV AIDS communication social marketing national and global programs policy development surveillance laboratory science and global engagement focusing on technical assistance and policy advice end quote we know that in Canada we have provinces and territories that are responsible for the delivery of health care and public health services this is I would argue one of the many key challenges in a coordinated approach to HIV prevention care treatment and support across this country just a few numbers to share with you with respect to this contentious issue of the undiagnosed numbers of HIV infection in Canada this is a very important issue in relation to the criminalization of HIV non-disclosure in that if you're not being tested for HIV and you're unaware of your HIV status there is no disclosure to be made what this graph shows is that a total of seventy four thousand one hundred and seventy four positive HIV test results have been reported to the public health agency of Canada's Center for Communicable Disease and Infection Control since testing began in November of 1985 through December 31st 2011 the CCDIC estimates that there were a cumulative total of seventy seven thousand six hundred and twenty persons diagnosed with HIV the prerequisite being that they actually were tested the CCDIC estimates that approximately twenty four thousand three hundred individuals have died so what we're doing is a little subtraction exercise seventy seven thousand six hundred and twenty minus twenty four thousand three hundred Canadians were therefore aware of their status since the estimated total of seventy three thousand three hundred persons living with HIV in Canada the remaining seventeen thousand nine hundred and eighty persons or approximately twenty five percent of prevalent cases were unaware of their HIV status so back to the issue of disclosure just chuck that little nugget away for our discussions in terms of the overall estimated number of HIV cases this differs by exposure categories and this is important to look at when you see these follow these blue lines so MSM means men who have sex with men the red line is injection drug use the sort of I'm not sure what color that is whatever this color is okay so lime heterosexual and then purple is heterosexual non endemic endemic do people understand the difference between that so if you come from a non endemic country so you're coming from maybe an immigrant from a country where HIV is endemic so we know that in a variety of context there are high concentrations of HIV infections so the reporting system is reporting folks from endemic countries versus those who are not and that they're only known risk factor is heterosexual sex so with approximately twenty four or so percent of people living with HIV infection in the MSM IDU category unaware of their HIV status whereas there was a higher proportion of people who were unaware of their HIV status approximately 34 percent in the heterosexual category that's combining endemic and non endemic heterosexual risk okay so keep that in mind so there are people who don't have any identifiable risk factors other than heterosexual sex from this graph you can see that the number of reported HIV positive tests have remained fairly constant between 1996 and 2001 I'm going to put a little shame on public health sidebar in there so what we'd like to have seen since we've had some thirty years of practice to get ahead of the epidemic what we'd like to see is a trend where the numbers are actually in a steady decline but we're not seeing that so is that an artifact of more access to testing more people heating the public health mantra of get tested know your status what is that an artifact of something for you to think about in terms of rates of HIV positive test reports among adults by province and territory there are a number of hard hit locations which speak to the unique contextual factors that vary from location to location some would argue that these differing rates across the country are related to issues about population density as well as provincial variability and access to testing uptake rates in terms of HIV testing and variability in terms of access to prevention interventions from homes to clean needles to methadone and again keeping in mind that those are provincial responsibilities right so in terms of how HIV is distributed by age you can see from this graph the differences between males and females in terms of age distribution there are potential implications for women within reproductive age particularly in regard to the spike you can see in the 30 to 39 year age category testing that many of these women may have become infected at a younger age and may have been diagnosed in the context of prenatal HIV screening programs prenatal screening for women across the country is recommended by the Canadian Medical Association as a means of preventing vertical transmission of the virus from the mother to the fetus there are no such targeted screening interventions for heterosexual men whereas gay men or men who have sex with men have historically speaking had a much higher rate of HIV testing uptake in Canada in terms of the proportion of reported age cases among adults by race ethnicity we can see from this graph that for example aboriginal populations are grossly overrepresented relative to their overall population size and this is a particular public health concern where current HIV prevention interventions may not be meeting the unique socioeconomic, cultural, gender or linguistic needs of more diverse populations these determinants of health according to the public health agency of Canada and for those of you who have read Dennis Raphael's work these determinants of health can synergistically impact on both health risks or health context as well as health outcomes we know from a public health perspective that key determinants of health can impact on health seeking behavior which is to say that based on the configuration of determinants of health some of which you can hopefully see in that schematic individuals may be more or less likely to seek out health services including HIV testing according to the public health agency of Canada determinants of health at the micro, meso and macro levels as indicated in this schematic are interconnected and impact on health across the lifespan it's important to note here that not all of these determinants of health are modifiable for example as much as some of us modify our actual age to something perhaps lower that is not a modifiable determinants of health whereas work environments are modifiable in that workplace safety regulations labor standards and policies can impact on health and they are modifiable so everybody kind of with me on that yes alright okay so banking all that information I'm going to carry it forward into part 2 so now let's have a look more specifically at public health and the law and again just a gentle disclaimer not a lawyer so accordingly the continuum of approaches to meeting diverse HIV prevention needs is subject to the context within which public health occurs however coercion is regarded as a dividing line if you will between voluntary public health measures and public health law interventions that are backed by law according to the interagency coalition on AIDS and development criminal law and some interventions under public law rely on coercion shifting gears slightly public health law consists of several core characteristics including public health activities central to government responsibilities relationships between the state and the populations the state serves the provision of population based services as informed by scientific evidence and finally the power to coerce for the protection of the public's health so there is within the public health remit what's referred to as a graduate graduated approach and this is an interesting model in that it begins with an initial complaint from an individual such as a public health personnel like a diagnosing nurse who brings to the attention of a medical officer of health or an MOH or for information about the client who is unable or unwilling to prevent the transmission of HIV it's the responsibility of the MOH to document the details to confirm an HIV diagnosis to determine whether the client received appropriate counseling at the time of diagnosis the MOH then assesses this information in conjunction with the diagnosing nurse if the client has a knowledge and capacity to comply that's essentially what they're trying to establish at this point does the individual have the knowledge and capacity to comply the client may be deemed unable to prevent HIV transmission for what are referred to as internal reasons such as organic mental illness or external reasons such as coercion from other persons or the client may be unwilling to prevent HIV transmission due to high risk behaviors but possesses the capacity to prevent transmission so again this is within the remit of the MOH so moving on then to level 1 this involves counseling and education whereby the diagnosing nurse provides education and monitoring referrals to care and treatment and discussion about legal issues so that's happening at level 1 at level 2 this requires a diagnosing nurse to assist the client in accessing food, housing counseling, health care and treatment and also involves regular reviews with the client at level 3 we see the MOH is again made aware that the risk continues and an issue is an order under section 29 of the public health act which in and of itself involves two steps the first step which contains the conditions of HIV disclosure, protection of partner, no sharing of needles no donation of blood or tissue, notification of residents and regular meeting with the diagnosing nurse, the second part of that is if unwilling or unable behaviors persist despite the order and intervention further limits are placed on the client's behaviors such as prohibiting activities that may place other individuals at risk and restrictions on where the person may go moving up one level level 4a is an apprehension order, level 4b is an isolation order and the last which is level 5 is the criminal level. So you've got all of these systems in place in this graduated model within public health at level 5 at the criminal level the client may be charged under the public health act and or the criminal code What I want to show you in this schematic is that as we see public health approaches shift from attempting to meet the complex challenges of preventing HIV risk behavior we see a moving way from voluntary to mandatory interventions that's depicted in the schematic. With this comes increasing intensity of case management and increasing coercion and increasing costs. This is the point at which public health powers can essentially be turned over to criminal powers in addressing HIV prevention. However based on the findings put forth by the federal provincial territorial expert working group on the issue of persons who fail to disclose their HIV status they suggest that a public health approach as opposed to a criminal approach provides greater scope for prevention confidentiality is maintained to a greater extent there's less stigmatization of the person living with HIV and that HIV is less likely to be driven underground in a public health approach versus a criminal approach. Most of you probably recognize this when the supreme court case was on all of the newspapers and everywhere this was their photo of choice so you've probably seen it many many times in relation to this particular issue about the recent supreme court decision with reference to the October 5th 2012 supreme court decision the challenge in this case in part is in defining when there is realistic possibility of HIV transmission. So as we kind of walk through this mental exercise, put yourself in the position of the person who is having to prove this. How do you know? How do you provide proof that there was a realistic possibility of HIV transmission? So just walk along with me in this scenario. What this means is that to address the issue of realistic possibility both the condom must be used and the person living with HIV must have a low or undetectable HIV viral load through the use and adherence to antiretroviral therapy. If both of these conditions are met there is no obligation under the criminal law to disclose one's HIV status. However, proving that both conditions were met can be problematic as you can appreciate. So from the supreme court decision the issue of realistic possibility of HIV transmission is problematized only in relation to vaginal sex. The court has not clarified how the requirement to disclose applies in the case of anal sex or oral sex for example. The scientific evidence to determine risk of transmission of HIV in the case of unprotected vaginal sex where ejaculation occurs and where the male partner is HIV positive ranges from 0.05% or 1 in 2000 to 0.26 or 1 in 384. Sorry? Thank you. I thought I did. This is good. Thank you. That's good. Cut. That's a wrap. Sorry. Further Everybody still with me? Don't make me throw this at you. Further Transmission is reduced up to 96% when the HIV positive partner is on antiretroviral medication. It's noteworthy that from the initial 1989 courier decision to the 2012 maybe or in DC decision advances in HIV treatment and viral testing have changed the evidence base of transmission probability. I would argue. So as we can see in this graph there have been a total of 123 HIV non-disclosure cases in Canada between 1989 and 2011. Of these 65 have been convicted while many are still before the courts and this is information that you can get from the Canadian HIV AIDS Legal Network. Richard Elliott has done a lot of work in this area. The majority of these charges have been against a male partner who refused to fail to inform their female partner that they were HIV positive before sexual intercourse and or did not use a condom during sexual intercourse. If we agree that the intent of criminalization of HIV non-disclosure is meant to protect public health and human rights, the question remains if the recent Supreme Court decision will advance public health or serve as a disincentive for individuals to be tested for HIV and that it may have the untoward consequence of further pushing HIV underground. Further the suggestion from organizations like the Legal Network and the Interagency Coalition on AIDS and Development is to revisit the possibility of an either or scenario and this is where either the use of a condom or an undetectable viral load could preclude criminal liability in cases of HIV non-disclosure. The suggestion is to further weigh the current scientific evidence against the likelihood of infection as well as the potential unintended impacts of criminalization of HIV non-disclosure in determining an approach that does not undermine the three decades, plus or minus of public health HIV policy and programming interventions. In particular the concern from public health about the reduction in HIV testing rates rather due to the perception of knowing your status means telling your status and as I described earlier that's not always the case. Oh, thanks. Okay so what does this mean that in terms of approximately 25% of the undiagnosed fraction of the population who are unaware of their HIV status? So in other words will the possibility of criminal sanctions increase or decrease the likelihood of individuals getting tested for HIV and where found to be HIV positive will infected individuals be more likely or less likely to discuss HIV prevention strategies with health care providers? What are the potential implications for care and treatment of people living with HIV in the face of criminalization? We know that the intersection of determinants of health can impact not only on initial HIV vulnerability but it could also be argued that the same determinants of health impact on health outcomes. So in an effort to capture these contextual factors which contribute to HIV infection rates it can be argued that the public health policies and procedures related to using the graduated approach which I explained to earlier in conjunction with mental health, social work, medical services and community health care allows for interventions at the level at which the unique circumstances pose the primary risk of initial infection. Some further considerations to frame our discussion we may want to consider how criminalization may increase stigma and discrimination, hinder HIV prevention efforts and I've already alluded to the issue around testing and the problematic therein. Contradict public health messages could be used as a tool to intimidate partner or sorry intimate partner abuse issues it's not based necessarily on current HIV research and I've alluded to some of the changes from the 1989 decision to the 2012 decision and it doesn't necessarily get at the root problems associated with HIV risk. So in Canada a person living with HIV can be prosecuted for not disclosing their HIV status before engaging in sexual activity that represents a significant risk of HIV transmission. So for the purposes of our discussion today I would ask that you consider that people can be prosecuted even if the sexual partner was not infected. I would also like to make sure that criminal law can be applied to exposure and not just actual transmission. That's an important issue to keep in mind. We're almost there. From a public health perspective I would ask that you consider the following points in your discussion both here but also back in your respective workplaces and classrooms prevention is the cornerstone of the Canadian public health response which necessitates prevention interventions at all levels. Primary, secondary, tertiary and must also consider the intersectionality of determinants of health that can lead to context of risk for HIV infection. And that to be most successful public health policy and programming interventions must utilize a range of interventions biomedical, behavioral, structural, etc. So as stated in my presentation today this continues to be a significant public health issue despite various notable successes both primary and secondary prevention remain ongoing challenges. So some possible ways forward include improving our understanding of biomedical, behavioral, social, structural drivers particularly as they inform the public health response vis-a-vis health programs and policies. The evolution of the approach so again we're seeing an erosion to what's been called historically AIDS exceptionalism and getting rid of funding that is targeted specifically and solely in HIV AIDS and looking at combining that with sexually transmitted blood-borne infections and tuberculosis which is actually the perspective that the public health agency of Canada is entertaining and collaborative approaches obviously are needed between governments across sectors including people living with HIV. And finally a collaborative approach as I said is really key to getting ahead of the epidemic both in Canada as well as globally. So by way of conclusion I'd like to turn the conversation over to you to grapple with the question that we're here today to discuss namely is HIV a public health or criminal matter and more to the point how do you weigh the evidence some of which is seemingly contradictory and determining which approach is better suited to address HIV prevention in a Canadian context. Thank you. I'll just do one shameless plug okay two quick ones Alex Hillman right there she's just about there she is actually my research manager in my research unit and we are developing an event in conjunction with the Art Gallery of Nova Scotia which will be held at the Art Gallery of Nova Scotia on Saturday March the 9th and it's a lunch and learn and we're going to be showing a film about this issue of HIV criminalization for non-disclosure and then we're having food and we're also having an art installation which is done collectively by a group of positive women and a local aid service organization and it's open to the public it's free we've got a Facebook event thing so like it send it around whatever if you want any more information about that event you can contact Alex and her I hope that's 2213 is correct we'll have 7806 or something before but I'll sort it out and the last one is is anybody here specifically working in HIV and or going to the Canadian Association of HIV Research Conference in Vancouver okay then that I don't need to get into so that's it I'll turn it over to you to ask questions and engage one another in a conversation about this particular issue oh hi can you get to the criminal sanction for non-disclosure of HIV through the public health existing legislation what in your opinion theoretically does this director's criminal sanction add you know why is it why do we have this feeling that it's important to have a separate criminal that we can get to directly when we can already get there through the public health route I guess I'm curious as to what problematic or helpful who in addition you think that is from my own perspective as a professor of health promotion I struggle with that because our focus is largely on primary and secondary prevention so much more upstream with the focus on energies resources etc in preventing initial infections then preventing onward infections and looking at how we can do that from a systems approach and in our work and Alex you can feel free to chime in it's not about looking at the big hammer of the criminal law to sort out something that from our perspective we still do see as within the arena of public health clearly remember that sort of toggle between it's a public health issue but within the public health act there is the choice or the opportunity to then toggle over into the criminal criminal justice and from my perspective it's a bit counter to the work that we do in health promotion other questions did anybody else want to answer that or feel free there should be a conversation not just you know what kind of evidence were they putting in who was there and why because I think everybody was expecting the case to go the other way potentially because of the research that we are in such a different world now how will they possibly reaffirm so what could you explain other than just sheer negligence in the part of the court to explain how you could have been able to do that to explain how you could have been able to work this aspect of the world view change in each of these so in the case of there were four charges brought against him around nondisclosure and three of the four stuck and the fourth one didn't because his viral load was low so interestingly and that was the Manitoba Supreme Court so at the provincial level they decided to do away with one of the charges but still that evidence of the other three were used in the Supreme Court discussion in terms of interveners for those of you who are aware of the work that the Canadian HIV AIDS legal network and other like Halco and others in Ontario actually were invited to participate in the process as interveners but you're right they and other individuals involved in that process would share your concern about that and it was a zero to nine decision so it was a unanimous decision so the question from some of the interveners was as you're posing given this vast amount of scientific evidence that didn't exist in 1989 was the courier decision why are we not making better use of that evidence to frame decisions and discussions about that it gets a little bit more complex with respect to the nature of the DC case where and this is a woman from Quebec where she had one instance of unprotected sex with her male partner they subsequently broke up he used that to charge her with aggravated sexual assault it was later proven that her viral load was undetectable so she theoretically posed no risk of transmission of the virus so it's an interesting kind of shoe horning of logic when on the one hand the likelihood of transmission is negligible but the intent of the law in this case is to this person is guilty of a criminal offence which aggravated sexual assault is a criminal offence so the concerns from people like Richard Elliott is are we then muddying the water like making a law that's on the books not good for either the person who is actually a victim of sexual assault as well as a person who is living with HIV so they would argue that in neither instance is it a perfect application of that particular law but please feel free to chime in people that's all I got sure and I think it ties into other questions to the way that you presented it it is why would nobody would disagree that we should have all the public health prevention measures that we can and pump all the money into that and that's great and wonderful and then we have someone who all those prevention measures and all the protection measures have not touched and that person is intent on transmitting HIV to others without their knowledge and why the heck would we not use law at this point and I'm not clear yet either on whether you think that the public health law coercive measures are worth utilizing and you were presenting them on a continuum so the continuum of public health measures whether they're contained within public health legislation itself or whether they go over into the criminal code why the heck not so the issue around intentionality is really important so there's lots of material available on this that if the person was doing this intentionally that's a very different they've been told don't do it they continue to do it they understand the consequences of their actions and they're still doing it willfully and intentionally that's a very very very very minute segment of the population and I would argue if somebody knows and just work with me on this if somebody knows they have a sexually transmitted infection like syphilis or herpes or gonorrhea or fill in the blank the question remains why are they not then being they're willfully have it they're not doing anything to take precautions so what is it about HIV that becomes this extraordinary situation that people can't sort of disentangle the yes this person did it intentionally in other cases we can see the the use of public health cease and desist orders or people being incarcerated temporarily because they won't stop doing what they're doing that issue of intentionality I would argue goes across a whole slew of behaviors and so the picking out HIV in relation to all of these other things that there is an intent to do harm to somebody else why then is HIV the focus of all of this psychic and other energies for me that's still a question I'm grappling with putting a lot of money and resources into a fix that doesn't actually get at the underlying issues that are at hand I would argue but can't I just say in response well fine will include syphilis and gonorrhea and any of the more serious STIs in that coercive measures area do you think that some coercive measures are appropriate so the camera's still rolling so I'm going to say yes and no and I'm going to say yes and no because from health promotion it doesn't resonate with the core philosophy of what health promotion is attempting to do from a broader public health remit yes I think in some instances particularly around the issue of intentionality then yes some coercive measures under public health might be necessary or required hi anybody over there in the cheap seats anybody else I have another one anybody else I'll be over there what do we know about why people do not know their status okay so we know that there are approximately 25% of people in Canada with HIV who don't know their status so do you remember I used the example of women are often found to be positive through prenatal screening right so that's a catchment that's been used I would say universally as a means of preventing vertical transmission of the virus from the mother to the fetus and there were studies that were done on this a long time ago that even monotherapy delivery would reduce the chances of the baby becoming infected so that tool has been there for a very long time there has not been and don't shoot me I'm just going to go out in a limb and say this even though the camera is rolling there is no comparable for heterosexual men so for example some of the studies that I've done in Nova Scotia elsewhere looking at why people don't get tested so what's the perception about you know why people would get tested and why they wouldn't and there's a whole range of things but one of the interesting things that we heard from pregnant women was no one ever asked for their so they get tested to prevent vertical transmission so they want to make sure if they know the mom is positive they can put her on antiretroviral therapy reduce the chances of vertical transmission down to virtually nothing but no one and all of the women without probing on my part said I thought I was really curious that I could ask that only only when I'm pregnant and be never in association with my male partner so there are some gaps in testing campaigns that I would suggest need to include in a user friendly gender appropriate way heterosexual males so gay men or men of sex with men historically are good to get tested pregnant women very few will not get tested and the way the Canadian Medical Association guidelines are currently stated is you get asked in your first trimester if you say no you get asked in your second trimester if you say no you get asked in your third trimester so you've got multiple opportunities to get at that potential undiagnosed population of women so women who are pregnant I would argue and have argued for a really long time to do more about engaging heterosexual men in this discussion where we see heterosexual men included in these discussions is largely their face on the front of the paper saying you know buddy X had sex with all of these people there was an outbreak when I was a grad student working at the Center for Disease Control or LCDC in Ottawa and the outbreak was in Conception Bay Newfoundland so all the surveillance people go to find out what's happening and it's one prolific fornicator who apparently knew of his status and continued to have sex so we really don't have a great mechanism to engage populations beyond women in prenatal context and men who have sex with men so I think we could do more in terms of how we approach testing so there's really no incentive now I would argue in light of this recent Supreme Court decision for people to be tested because you see the words HIV and criminalization in the same sentence or in the same paragraph and it immediately raises concerns about why would I want to get tested I don't want to know that there was a question here yeah I think this is kind of some testing and I think one of the things is the nature of this itself especially for other STIs is the fact that you can completely asymptomatic the entire time you carry them so whether or not you even can be again like you mentioned kind of the screening screening is there but who's getting this a lot of people don't even know they haven't used the gamut completely asymptomatic with them and there's a lot of STDs and HIV as well that people can go for a very long period of time completely asymptomatic so again there's nothing sort of tweaking them to get tested so that's a good point there was a question here yeah I was just going to ask around and how criminalization would impact people who would otherwise have gotten tested but would not get tested now because they're in the fear of criminalization and is there any data on this? yeah that's a really good question we're actually starting in Nova Scotia a rapid-point care HIV testing pilot project and we're looking at two populations at enhanced risk for HIV infection and actually offering them an additional test or rapid HIV point of care test which means you essentially get your test result in the same meeting and if it's positive then it would be sent forward for a confirmatory test and I think that's actually going to be one of the issues that we look at is are people declining testing offers more as a result of this so you know we can track that for example in Nova Scotia for a duper great testing uptake rate data other than through the prenatal screening programs so I think that's a question that we ought to be paying a lot of attention to for sure the other thing that I would wonder if it comes into place males are traditionally not seen in the doctor's office or between late adolescence through until I don't know between birth and death so that's a piece where as women tend to be seen maybe a bit more often I don't have the date on that so that would potentially drop the opportunity for inhibits right off the top so that surely would increase the numbers there in terms of people not being present to be asked and the other piece I wonder about this is just curious on my part is how comfortable are primary care practitioners be they physicians, nurse practitioners or whoever in looking at a known heterosexual male and saying have you had HIV testing done super interesting questions and I think that is something that we need to pay more attention to we need to pay more attention to men's health issues across the board and not just HIV so you can look at things like okay how many of you have had this experience you're driving along and there's a city bus in front of you and you're just chatting away with somebody in the seat beside you and you get stuck behind the same bus the whole way and the back of the bus has a big black and white butt cheek about what getting your bits and bobs checked and it's what right that's the one and so that's changing the sort of public discourse about guys dropping their trousers maybe just long enough to have things checked out for a minute or two and then off they go so I think that the approach to normalizing screening and testing for men is a really important part of the HIV piece but it's also a really important part for men's and women's health across the board because your observation is quite right women will often go in and get information or condoms or other things for their male partners and male partners often don't feel comfortable going in unless that's falling off or bleeding or something I mean I thought I had to excuse that I saw that very clearly I worked back in the Arctic for almost a while and that was probably the biggest most glaring glitch in the primary healthcare scene there was the almost complete absence of men in the clinics until they were 75 and stuff starts to go wrong and they need a lot of care so I think there can be done around the upstream approach to screening there was a hand up there somewhere no no there was anybody else I was wondering if you could go back to the point you made with the criminal code and how that's planned or sure question I was actually this morning looking at statistics of who is who is charging whom with what kinds of whatever and most of it's heterosexual charges and you would think that given the rates of infection among men who have sex with men that there'd be a lot more of that going on but there's not so it's kind of an interesting phenomenon to look at because what does that say so gay men are better at sorting it out themselves they don't trust the criminal justice system they're okay with barebacking and sort of surro-sorting amongst themselves and that's a sufficient sufficiently informed approach it's an interesting it's a very interesting question because the courts didn't weigh in on oral sex or anal sex and this was on vaginal sex because in most instances those are the cases that are coming before the court and also there's a greater risk of transmission from an infected male to a female versus an infected female to a male depending on the circumstances but general speaking are they still trying to create legislation to cover the other forms of sex or are they you've got to cover this all I think it would be very interesting to see what the Supreme Court justices do under downtime after they make these kinds of decisions you know do they then have informal talks like hey you know we should really get back together and have a more fulsome conversation about anal sex I mean I don't know how I don't know what the you know I don't know what the impetus would be but I think it's actually quite interesting and the Canadian HADA's legal network is actually questioning that if the test is the evidence is there for probability of transmission through oral sex anal sex and vaginal sex can we get a little bit more either weigh in on this issue of transmission through injection drug use because people share needles so you know where does the remit to apply this transmission issue where does it end or you know is this actually the way we should be going I would ask that question too Hi I work at the other in the lab so we do HIV screening and I often wonder that myself we never see any males or very seldom why do they never when a couple decide to have a male why do they never ask the male to be screened I mean wouldn't that make the excellent conversation Yeah I mean it would be and in fact most of the women that we interviewed in our HIV and testing studies both nationally and provincially asked that same question you know I didn't get pregnant sitting at home watching late night movies I mean that's a good opportunity to have that discussion I would assume that most of them would be agreeable Yeah I think that's a really interesting question about how to include more heterosexual males in most of the relationships I know Lynette is at the back and she was being very patient can we hear one last from Lynette Sure No pressure Make it good Lynette, make it count There's an aspect of this that I also should I understand that it's one of the legal sides so but it's in relation to as I understand it Canada's criminalization is through this mechanism of this reform to present for sex and it's not through legal mechanisms that would look at harm or attention to harm so I just want to say that a little bit better isn't this and the people there is about that I mean if you just touched on the violations of sex and it's not really about harm or attention to harm then we would see that you know we've got sexual assault going on all over the place as women live all sorts of things or violence was all sorts of things so we've mattered to the partners so then we really have not just HIV being picked up in in some of the sexist conditions HIV being picked up in all of the factors in which we go on but I don't know much then It's an issue of fraud where there are options in the law to get more close to harm or attention Do you want to talk? It's an issue of it's a consequence of fraud Right so it's actually been a development within the courts not only in criminal law but in civil law more generally to be asking whether the transmission of a sexually transmitted disease with knowledge that it may be being transmitted through a through a sexual act whether that vitiates the consent of the person who is the victim in the circumstances and the courts have gradually moved over centuries to a finding by Canadian courts that it does actually vitiate the consent if you have not revealed to the other person the presence of a sexually transmitted disease and the fact that it may be transmitted if protection is not taken so that is not only in the criminal cases but your entirety correct that in my understanding the use of the specific criminal law power which has been only gradually happening and in response to HIV and I don't know of cases where other sexually transmitted diseases have been implied under discussion in the cases that has gradually happened and it's actually not only sexual assault provisions though we've had convictions for murder in the case of criminalization of HIV and transmission of HIV in those circumstances and yes Canada has been doing so in my understanding more so than in many other countries I did want to be sure that the audience wasn't left with the impression that this is only to do with vaginal intercourse the use of the criminal provisions it's not that at all I may have been out of the room when it was but it may be that the cases so far have all been in the context of vaginal intercourse I would have to look back at the range of them to see but anyway it's not that the criminal code provisions read that way and perhaps they should be changed they would certainly take circumstances of men having sex with men for instance as one of the areas that could be used whether it is murder, manslaughter or assault or sexual assault or assault causing a bodily harm in any of those range so before I thank Jackie did you want to say one last thing? No just thank you very much for being here before I thank Jackie I have a few announcements myself one is that our next seminar is on Friday February 8th and it is Amy Kapczynski from Yale Law School speaking on non-excludability and the limits of patents in furthering health there are two events being hosted by the novel tech ethics group first is at 7pm Tuesday January 29th these are both cafe scientific so they're open to the public and meant to appeal to the public in fact this one is being held at Dirty Nellies and it is on the human aid trade there are three different speakers one of whom is Jocelyn Downey and on Monday February 4th 7pm at Justice Cafe another cafe scientific on crisis of conscience conscientious refusal by healthcare providers and access to care Barbara do we have these on the table okay so or and I have them here I'm going to take them also well so Jackie was very brave in coming before this harshly legal audience and speaking to us on whether HIV non-disclosure should be criminalized or whether it should remain a public health measure and whether it's counterproductive to have the criminal law operating in a parent conjunction with public health and we're very grateful to you Jackie and please join me in saying thank you